Bleeding per Rectum History # Bleeding per Rectum # Onset & Duration Colour Bright red Altered Mixed (fresh + altered) → PPV higher when dark and bright mixed blood than dark or bright blood alone Melena (Sticky, blackish, difficult to flush) Timing with Defecation Before Mixed (towards malignancy) Streaky (fissure, low rectal CA) After Dribbling Spurting Amount? Cup/diapers/clots Any Other Bleeding Manifestations Associated Anal Pain? Fissure, abscess, hematoma, anal carcinoma Uncomplicated hemorrhoids or rectal cancer are not usually painful Any Lump at Anus?
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Haematuria History # True Haematuria or Not # Exact Color: Dark tea color (OJ) Exclude Pseudohaematuria: Itching & steatorrhoea Factitious Haematuria: Munchausen’s syndrome, narcotic seeking behavior Past History # Bleeding diathesis & other bleeding manifestations Relation of Gross Haematuria to Urinary Stream # Initial (urethra distal to urogenital diaphragm) Total (bladder proper or upper urinary tract) Terminal (trigone/ bladder neck of prostatic urethra) Painless or Painful # Painless: Malignant but can cause pain due to clot colics Painful: Urinary tract infection or calculus, papillary necrosis, passage of clots, obstruction, loin-pain haematuria syndrome, glomerulonephritis Clots # Indicate non-glomerular bleeding Large, thick, irregular clots - bladder Small, linear clots - upper tract Passage of tissues Associated Symptoms # LUTS Fever, chills & rigors with loin pain or suprapubic pain Any loin pain with self-felt loin lumps (Classic triad of RCC 10% - haematuria+loin pain+loin mass) Tissue passage Vaginal or penile discharge, sexual activity Presence of urinary catheter Relation to menstruation (endometriosis) Anemic symptoms GU History # History of BPH, stone disease (Hx of GU cancers) Hx of instrumentation Hx of pelvic irradiation Aetiology for Malignancies # Smoking Occupational exposure to dye stuffs and rubber compounds Hx of travel to middle east countries (Schistosoma haematobium) Family history malignancy (bleeding diathesis + renal disease) Metastatic Features # Fitness for Sx PMHx- # PSHx- # Drug Hx- # Antiplatelets or anticoagulants, cyclophosphamide SHx- # Job(risk factors)/family Smoking/alcohol Disability/concerns Examination # General # Anemia/plethora Facial oedema/ periorbital oedema, rather than ankle edema suggest renal pathology Unilateral or bilateral ankle edema- think of Iliac vein compression in unilateral edema Bone tenderness Muscle weakness Malignant cachexia- anaemia asthenia anorexia Ask for BP Abdomen # Palpable suprapubic mass- distended bladder, anterior wall bladder tumor Ballotable renal mass Hepatomegaly Ascites DRE & genital Ex (non-reducing left varicocele) Summary # This 60 yrs old ASA 2, MET score >4, male patient with episodic visible haematuria over 3 months associated with occasional clots & passage of tissues.
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